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Almost 80% of Visits to Bronx Center Rank as Missed Chances for HIV Diagnosis
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IDWeek 2014, October 8-12, 2014, Philadelphia
Mark Mascolini
Almost 80% of medical visits to Montefiore Medical Center in the Bronx, New York represent missed opportunities for HIV diagnosis, according to a review of 218 people newly diagnosed with HIV in 2012 and 2013 [1]. Almost all of these missed opportunities occurred in emergency or outpatient departments.
Despite aggressive HIV screening advice from the Centers for Disease Control and Prevention (CDC), many US residents continue to be diagnosed with HIV at low CD4 counts or missed entirely. The CDC estimates that 18% of HIV-positive people in the United States remain undiagnosed [2]. Researchers at Montefiore Medical Center hypothesized that many people diagnosed with HIV in this urban area with high HIV prevalence had frequent previous visits to the center when they were not tested. They defined a missed opportunity for diagnosis as one or more healthcare visits within 3 years of HIV diagnosis when HIV testing was not performed in people who had a prior negative test or no prior test.
Of the 218 study participants, median age stood at 37 years and 140 (64%) were male. About half of the study group (52%) was black, 30% Latino, 8% multiracial, and 6% white. Among men, sex between men was the more frequent HIV transmission mode (59%), followed by heterosexual sex (38%). Heterosexual sex was by far the most frequent transmission mode among women (94%). Most people (60%) were diagnosed in outpatient departments, followed by inpatient units (19%) and emergency and urgent-care clinics (12%). Seventy-four people (34%) had a prior negative HIV test.
Almost one third of these people (31%) had a sub-200 CD4 count when diagnosed. Median CD4 count at diagnosis was 320 and median viral load 33,131 copies. At their HIV diagnosis visit, nearly one quarter of the study group (22%) had no symptoms, while 16% had nonspecific symptoms, 14% gynecologic, genitourinary, or sexually transmitted disease (GYN/GU/STD) complaints, 13% opportunistic infections, and 11% follow-up after a high-risk contact.
Among 117 people with a previous visit to Montefiore Medical Center, 66 (56%) did not have a prior HIV test and 51 did. The 66 people without a prior HIV test had 350 visits to the center, 50% to an outpatient department and 46% to an emergency or urgent-care department.
Among the 66 people without a prior HIV test, there were 309 missed opportunities for testing (4.7 per patient). Half of these missed opportunities occurred in emergency and urgent-care departments, and 45% occurred in outpatient departments. Among the 51 people with a prior HIV test, there were 185 missed opportunities for testing. Overall, more than 79% of visits represented missed opportunities for earlier HIV diagnosis.
Of the 309 missed opportunities in people without a prior HIV test, 29% of visits involved nonspecific symptoms, 23% involved health care maintenance or chronic disease follow-up, 20% involved lower and upper respiratory symptoms, 14% involved musculoskeletal problems or acute trauma, and 11% involved GYN/GU/STD symptoms. The researchers noted only rare instances of a clear HIV "red flag," such as oral thrush, at visits representing missed opportunities.
The Montefiore team concluded that "HIV-positive patients continue to present late to care, with variable symptomatology, low CD4 [count], high viral load, and commonly utilize outpatient departments and emergency departments, where missed opportunities for early diagnosis are common." They stressed the need for "policies that address more systematic, and routine testing across healthcare delivery systems . . . to prevent HIV transmission."
References
1. Liggett A, Futterman D, Umanski G, Selwyn P. Missed opportunities for HIV diagnosis at an urban medical center in Bronx, NY. IDWeek 2014. October 8-12, 2014, Philadelphia. Abstract 1521.
2. Centers for Disease Control and Prevention. CDC fact sheet: HIV in the United States: the stages of care. 2012. www.cdc.gov/nchhstp/newsroom/docs/HIV-Stages-of-Care-Factsheet-508.pdf
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